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The Situation of Mental Illness

The Rosenhan experiment was a famous experiment into the validity of psychiatric diagnosis conducted by psychologist David Rosenhan in 1973. It was published in the journal Science under the title “On being sane in insane places.” The study is considered an important and influential criticism of psychiatric diagnosis.

Rosenhan’s study consisted of two parts. The first part involved the use of healthy associates or “pseudopatients” who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in various locations in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had not experienced any more hallucinations. Hospital staff failed to detect a single pseudopatient, and instead believed that all of the pseudopatients exhibited symptoms of ongoing mental illness. Several were confined for months. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release.

The second part involved asking staff at a psychiatric hospital to detect non-existent “fake” patients. The staff falsely identified large numbers of genuine patients as impostors.

The study concluded, “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals” and also illustrated the dangers of depersonalization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels might be a solution and recommended education to make psychiatric workers more aware of the social psychology of their facilities.

Claudia Hammond revisits . . . David Rosenhan’s Pseudo-Patient Study, gaining access to his unpublished personal papers to discover how it changed our understanding of the human mind, and its impact 40 years on.

After Rosenhan published On Being Sane in Insane Places in the journal Science in 1973, the psychiatric profession went on the defensive to protest its diagnostic competence. The study struck at the heart of their attempts to medicalise psychiatry and be accepted as proper doctors. Its impact was felt when the third edition of the profession’s bible, the Diagnostic and Statistical Manual, came out in 1980: changes had been made which brought more rigour to the diagnostic process.

However, as Claudia discovers from Rosenhan’s unpublished papers, for him the study was less an experiment of diagnostic efficacy than an anthropological survey of psychiatric wards. In a chapter of the book he never finished, she reads his poignant account of his own first admission, and his sense that “minimal attention was paid to my presence, as if I hardly existed.”

Now suffering ill health and unable to speak, Rosenhan delegates his friends and colleagues professor of social psychology at Stanford University Lee Ross and clinical psychologist Florence Keller to speak to Claudia and show her the box containing previously unpublished material which throws new light on one of the most controversial and famous psychology experiments.

Americans, particularly if they are of a certain leftward-leaning, college-educated type, worry about our country’s blunders into other cultures. In some circles, it is easy to make friends with a rousing rant about the McDonald’s near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world’s understanding of mental health and illness. We may indeed be far along in homogenizing the way the world goes mad.

This unnerving possibility springs from recent research by a loose group of anthropologists and cross-cultural psychiatrists. Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places. In some Southeast Asian cultures, men have been known to experience what is called amok, an episode of murderous rage followed by amnesia; men in the region also suffer from koro, which is characterized by the debilitating certainty that their genitals are retracting into their bodies. Across the fertile crescent of the Middle East there is zar, a condition related to spirit-possession beliefs that brings forth dissociative episodes of laughing, shouting and singing.

The diversity that can be found across cultures can be seen across time as well. In his book “Mad Travelers,” the philosopher Ian Hacking documents the fleeting appearance in the 1890s of a fugue state in which European men would walk in a trance for hundreds of miles with no knowledge of their identities. The hysterical-leg paralysis that afflicted thousands of middle-class women in the late 19th century not only gives us a visceral understanding of the restrictions set on women’s social roles at the time but can also be seen from this distance as a social role itself — the troubled unconscious minds of a certain class of women speaking the idiom of distress of their time.

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In any given era, those who minister to the mentally ill — doctors or shamans or priests — inadvertently help to select which symptoms will be recognized as legitimate. Because the troubled mind has been influenced by healers of diverse religious and scientific persuasions, the forms of madness from one place and time often look remarkably different from the forms of madness in another.

That is until recently.

For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.

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What is being missed, . . .[some doctors] have suggested, is a deep understanding of how the expectations and beliefs of the sufferer shape their suffering. “Culture shapes the way general psychopathology is going to be translated partially or completely into specific psychopathology. . . . When[, for example,] there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.”

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THE IDEA THAT our Western conception of mental health and illness might be shaping the expression of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of our drugs, our illness categories and our theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs. After all, we now have machines that can literally watch the mind at work. We can change the chemistry of the brain in a variety of interesting ways and we can examine DNA sequences for abnormalities. The assumption is that these remarkable scientific advances have allowed modern-day practitioners to avoid the blind spots and cultural biases of their predecessors.

Modern-day mental-health practitioners often look back at previous generations of psychiatrists and psychologists with a thinly veiled pity, wondering how they could have been so swept away by the cultural currents of their time. The confident pronouncements of Victorian-era doctors regarding the epidemic of hysterical women are now dismissed as cultural artifacts. Similarly, illnesses found only in other cultures are often treated like carnival sideshows. . . .

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Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. . . . It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

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CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”

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To read the entirety of Waters’s fascinating article (including an illuminating discussion of how the “brain disease” concept of mental illness may have increased, not decreased, the stigma of mental illness and thus hurt the very people it was supposed to help), click here. (Thanks to Situationist friend, Andrew Perlman for suggesting this article to us.)